NEW PATIENT FORM - CHILD

Child's Name

Date of Birth *

First Name *

Last Name *

Preferred Name

Parent 1

First name *

Last name *

Mobile Phone Number *

Work Phone Number

Home Phone Number

Home Address *

City *

State *

Postcode *

Email Address *

Occupation *

Parent 2

First Name

Last Name

Address

Suburb

Post Code

Home Phone

Work Phone

Mobile

Email

Occupation

Person Responsible for fees

Name *

Address

Post Code

Phone

Do you have health insurance? *

Yes    No

Dental    Hospital

Which Fund?

Medical History

 Rheumatic Fever
 Hepatitis
 Lung disease
 Asthma
 Heart problems
 Digestive problems
 Diabetes
 Anxiety
 ADHD
 Speech or hearing problems
 Epilepsy

Has your child had any major surgery?

Any other relevant medical history?

Allergies and adverse reactions

Does your child have any allergies?
-- Please select -- Yes No

If Yes state allergy

Emergency plan

Medicines

Please indicate any medications that your child is currently taking (including natural therapies).

Orthodontic information

Has your child had previously?

Orthodontic opinion
-- Please select -- Yes No

Orthodontic treatment
-- Please select -- Yes No

In your own words, what concerns you about your child's teeth. What is the purpose of your visit.

Who is concerned about your child's teeth and/or jaws?
-- Please select -- Your Child You/family Your child's dentist No one

Does your child have a history of trauma to the teeth or jaw?
-- Please select -- Yes No

If Yes, when was the accident/injury?

Is there anything about your child you want to discuss with Dr Yusupov in private?:
-- Please select -- Yes No

General dentist

Name

Location

Date of last check up

Referrals, correspondence and appointments

Who recommended our practice to you?

Are you happy for us to email your reports?

To you
-- Please select -- Yes No

To your dentist
-- Please select -- Yes No

To other specialists
-- Please select -- Yes No

Can we SMS appointment reminders to you?
-- Please select -- Yes No

I agree to be responsible for all payment of fees and understand that payment is due at the time of the service.